Appreciate the thoughtful response, you've inspired me to dust off my acct
From my experiences currently as a resident at an academic program, there seems to be a disconnect between what I see and what SDN describes. Job market wise, things are better than I anticipated with reading SDN. Every one of our graduates has found a job with their desirable characteristics (location, academics, etc). The surprise has been the limited # of job offers, but this may be more due to 'real life' outside the path we've all shared to this point (e.g. 12 college acceptances, 12 medschool acceptances, 20 interview acceptances). I'd have to ask some of my non-med friends, but I get the impression their first jobs they had maybe 2 or 3 offers, so maybe it's not that surprising? Nobody has done fellowship, nobody has taken a job they didn't really want, nobody was relegated to East BF.
I share pessimism about the field, but mainly in the areas of academics and 'slice of the pie'. I've seen some surgeons avoid what's best for the patient because it doesn't involve surgery (whether by ignorance or greed). I've seen some med oncs avoid what's best for the patient because they wanted to try out a new drug first. I've also seen some med oncs laughably 'prescribe' explicit radiation regimens (yes, this was at an academic center, what a f*!king embarrassment). Given that we're a terminal referral field (e.g. we don't bring patients into the cancer center fold, they get referred to us), I am *very* worried about losing autonomy and becoming the guy in the basement they order around if it suits them. This is particularly concerning with the era of 'batch payment', where I worry the med onc is going to decide they'd rather blow $80k on a drug that works 20% of the time instead of properly referring the patient to receive $80k of ablative therapy to oligomets that works 95% of the time. As a small field, I think it's relatively easy for us to get bullied around. We have a MASSIVE value benefit to cancer care that I worry will be crunched because the "right" doctors aren't making money off it.
Academic radiation oncology has growing challenges as well. Many departments seem to have clashes with their cancer centers on how much $ they get to keep in department, and are being squeezed. This has led to salary freezes, reliance on buying up satellites (where they can pay a 'pseudo-academic' salary and reap the benefits), and reliance on residents (free labor as the GME office pays them) to do administrative tasks instead of spending $90k on an NP/PA. I've seen attending physicians grumble that they need 100% resident coverage so *they* don't have to do the prior auths, the referral requests, the records requests, the disability forms, the FMLA paperwork, the drug refill requests, etc. In departments without a heavy endowment/charitable funds, it seems like a common theme: Hospital/cancer center demands PP production, while paying academic salary and NOT hiring PP support staff; the dept chair still wants to be 'academic' so places academic demands (teaching, research) on faculty without being able to provide any support outside of residents. Thus, the solution comes down to "get more residents!" as they fulfill two needs: they're free labor to do the work of support staff, and they're the source of departmental research. This doesn't seem to be unique, and fully 'academic' situations seem to be the exception. I can see many residents in these systems feeling 'used' and not being shy about passing on those perceptions to prospective residents...
How does this compare to other specialties though? I can't really say as I haven't examined it much. I recall from my internship that MANY more of the residents were inclined towards private practice jobs, so there wasn't much interest in doing academic things (teaching, research, excelling on boards), and residents accordingly punched the clock just biding their time until pulling a real paycheck. There didn't seem to be as many 'self-inflicted' demands on the residents. It wasn't a small field either so if you pissed off your attending by refusing to do their scut work, BFD, they didn't have any role in you getting a job anyways.
